15 The Ongoing Crisis of Neonatal Opioid Withdrawal Syndrome
Sydney Herchenbach
Relevance of NOWS
As the opioid epidemic has become a major crisis in the United States, there is a higher disease rate of Neonatal Opioid Withdrawal Syndrome (NOWS). A significant increase of reproductive-aged women with opioid use disorder (OUD) has created a growing national problem and public health burden of infants with NOWS. In 2018, an estimated 80 newborns were diagnosed with NOWS every day, averaging one baby every 19 minutes. (Ko et al., 2017). NOWS is considered a ‘hidden consequence’ of the opioid epidemic because of the lack of awareness surrounding this disease. Due to the negative impacts of NOWS, it is an urgent issue that needs to be focused on in the opioid epidemic.
Background
NOWS was previously grouped in the term Neonatal Abstinence Syndrome (NAS), referring to a variety of drug exposure in the womb. Narrowing down to only opioids changed the name of the disease to NOWS (Eaves et al., 2021). NOWS is a withdrawal syndrome that infants experience because of fetal exposure to opioids. Pregnant women taking prescription opioids or illegal opioids, such as heroin, put their babies at risk for developing NOWS. Once they are born, they can experience withdrawal symptoms that include experience irritability, tremors, uncontrolled body movements, trouble sleeping, diarrhea, vomiting, sweating/fever, and intense crying (Bakhireva et al., 2019).
Additionally, NOWS can cause low birth weight, difficulty swallowing and digesting food, trouble breathing, and seizures (Bakhireva et al., 2019). A baby with NOWS is very sensitive to noise, sense, and touch, which results in living in a state of agitation (Lawlor et al., 2017). In most cases, the baby refuses to eat in this state and starts to lose weight, whereas non-NOWS infants regularly eat and gain weight daily. Many factors influence how severe NOWS cases can be, including how fast the mother breaks down substances and how they affect her body, the type of opioid used, the length of time and frequency the baby was exposed, and if other substances were used during the pregnancy. The frequency of opioid use is one of the most important factors because, in terms of NOWS, every time counts. More frequent exposure results in the infant undergoing more serious treatment (Eaves et al., 2021). The higher the exposure, the harsher the symptoms are. Infants born with NOWS are at an increased risk for behavioral, educational, and mental health problems (Shrestha et al., 2021). Long-term follow-up of infants born with NOWS is extremely difficult, so the extent of long-term consequences is still being researched (Milliren et al., 2018).
Cost Burden
In 2012, the total hospital costs to treat NOWS exceeded $310 million dollars, averaging $22,550 per infant (Milliren et al., 2018). Medicaid has been responsible for about 80% of these charges. (Lee et al., 2021) The high expenses are a result of NICU charges. Nationwide, a one-day NICU stay is $6,500-8,300, averaging around $58,100 per infant per week (Milliren et al., 2018). While some babies only stay in the NICU for a few days, others spend weeks or months, depending on the severity of their condition. Hence, why the factors that determine the severity of the condition mentioned above are so crucial. The more severe health conditions result in the most resources used and the highest costs. With these high costs, it takes a large amount of the state and federal budget to address NOWS.
Prevention – Mothers
Fortunately, NOWS is a preventable and treatable disease (Villapiano et al., 2017). From 1999 to 2010, prescriptions from opioid pain relievers have quadrupled (Shah et al., 2017). As a primary prevention strategy, focusing on clinician education about the sensitivity of prescribing opioid medications to pregnant women, women trying to become pregnant, and women aged 18-44 as they are considered reproductive age. Exposing women to unnecessary opioids increases the chances of opioid dependency and misuse (Peacock-Chambers et al., 2019). To combat NOWS, it is important to focus on planning and preconception care for women using opioids as another primary prevention strategy. During any type of screening, if a woman mentions any use of opioids, they should be educated on NOWS disease and the risks they expose their infant to. More than that, the clinician should ensure they have access to contraceptives and birth control if desired. Around 86% of pregnancies among women that use opioids are unintended or accidental (Ko et al., 2017). Decreasing the prevalence of accidental pregnancies can reduce NOWS cases.
Treatment
Historically, Finnegan Neonatal Abstinence Scoring System (FNASS) score is the most commonly used survey to quantify the severity of NOWS using assessment questions starting two hours after birth and repeated every three to four hours (Oji-Mmuo et al., 2019). Babies with three scores ≥8 or two scores ≥12.6 are sent to the NICU for treatment (Zimmermann-Baer et al., 2010). New research is pushing towards the Eat, Sleep, Console Model, a new method recently introduced to hospitals to monitor and treat newborns with NOWS. The ultimate goal of this approach is to avoid sending the baby straight to the NICU, reducing costs, eliminating the separation between mother and baby, and preventing morphine administration. Instead, nurses encourage the mother to engage in skin-to-skin contact in a quiet room with low light and frequent nursing (Grisham et al., 2019). A novel treatment is the Managing Abstinence in Newborns Program (MAiN), developed by Dr. Jennifer Hudson at Prisma Health Upstate. The MAiN Program consists of hospital services and clinical pathways to provide support, education, and resources to mothers using opioids during pregnancy with the goal of minimizing the risk of health problems for their babies. The MAiN model has been shown to be cost-saving, safe, and effective (Dickes et al., 2017).
Finally, educating the parents on properly caring for a baby with NOWS before they leave the hospital is essential. For example, making sure the music, televisions, and radios are turned down or off, promoting sleep, not letting people other than parents hold them, and suggesting cuddle carriers so the baby has skin-to-skin contact as much as possible are examples that clinicians should explain to parents (Lawlor et al., 2017).
Conclusion
Due to the high prevalence and lack of education, NOWS is becoming a costly burden to healthcare but could be prevented. In the future, more research is needed to establish a universal standard of care, which is currently lacking. Each case is treated differently depending on the severity, and hospitals use different approaches worldwide. Infants born with NOWS must be followed through childhood and adolescence to determine the lasting effects of opioid exposure and need psychiatric evaluations routinely.
Review Questions
1. True or false: NAS and NOWS are the same disease, just different names that have evolved over time.
a. True
b. False
2. How many newborns were diagnosed with NOWS every day in 2018?
a. 85
b. 80
c. 75
d. 70
3. The high expenses associated with NOWS are a result of _____.
a. Morphine expenses
b. NICU charges
c. Withdrawal medication charges
d. Legal fees
References
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a natural, semisynthetic, or synthetic substance that typically binds to the same cell receptors as opium and produces similar narcotic effects (such as sedation, pain relief, slowed breathing, and euphoria)
often painful physical and psychological symptoms that follows the discontinuance of an addictive drug
quick excitability to annoyance, impatience, or anger
a trembling or shaking usually from physical weakness, emotional stress, or disease
An abnormal electrical discharge in the brain.
A state or feeling of being agitated and restless.
Physical dependence on opioids.
incorrect or improper use
also called birth control, they are the methods, medicines, and devices used to prevent pregnancy
also called contraceptives, it is the methods, medicines, and devices used to prevent pregnancy
a bitter crystalline addictive narcotic base C17H19NO3 that is the principal alkaloid of opium and is used in the form of a soluble salt (such as a hydrochloride or a sulfate) as an analgesic and sedative
